Over the past 20 years, the number of amputations and surgical revascularizations for peripheral arterial disease has significantly decreased, according to a cohort study.

As the overall use of revascularization rose (from 91 to 118/100,000 person-years), the amputation rate dropped (from 13 to 5/100,000 person-years). The study was performed on a cohort of 773 residents (mean age 68) of Olmstead County, Minn., who underwent 1,906 limb revascularization procedures from 1990 to 2009.

In the earlier years of the study, physicians showed a preference for using endovascular treatment for claudication and surgery for critical limb ischemia.

But from 1992 to 2007, there was a significant decrease in surgical procedures for limb ischemia and other indications (70 to 30/100,000 person-years), with significant increases in endovascular (19 to 79/100,000 person-years) and hybrid procedures (5 to 10/100,000 person-years), Jeff Nienaber, MD, and colleagues from the Mayo Clinic reported at the Society for Vascular Surgery conference in San Francisco.

Surgery Bests Endovascular Fix of AAA

The long-term outcomes of minimally invasive repair of abdominal aortic aneurysms (AAA) were not as good as those for open surgical repair, according to another Mayo Clinic study presented at the Society for Vascular Surgery conference.

At 5 years, all-cause mortality was lower for open surgery (23% versus 32%), and freedom from reintervention was higher after surgery (87% versus 74%). Both approaches had the same rate of freedom from complications (66%) for the 1,350 propensity matched cohorts.

However, endovascular repair had fewer complications at 30 days (13% versus 25%), while the 30-day all-cause mortality rate was not different (1% versus 1.3%), reported Thomas C. Bower, MD, and colleagues from the Mayo Clinic in Rochester, Minn.

Two variables were associated with all-cause mortality: the Society for Vascular Surgery (SVS)-comorbidity score and age (mean age here was 74).

Anti-Clotting Tests 'Normal' in Therapeutic Dabigatran

Several tests commonly used to measure anticoagulation levels lacked sensitivity in distinguishing therapeutic from sub- and supratherapeutic levels of dabigatran (Pradaxa) in blood samples taken from 35 anticoagulated patients (150 mg twice daily).

Using multiple reagents, researchers found 29% of samples were insensitive to prothrombin time, 18% to activated partial thromboplastin time (aPTT), and 40% to activated clotting time, according to Emily M. Hawes, PharmD, of the University of North Carolina in Chapel Hill, and colleagues.

Current practice guidelines from the American Society of Hematology state that in a patient on dabigatran who is bleeding, "a normal aPTT is an indicator that dabigatran would be unlikely to contribute to bleeding," which is contrary to the finding in this study, researchers pointed out online in Clinical Haemostasis and Thrombosis.

The most useful assay for determining subtherapeutic dabigatran was thrombin clotting time, while ecarin chromogenic assay, ecarin clotting time, and dilute thrombin time were best for determining therapeutic and supratherapeutic dabigatran.

The agency said it found sufficient evidence to cover the use of dual-chamber pacemakers for the treatment of nonreversible symptomatic bradycardia due to sinus node dysfunction and second- and/or third-degree atrioventricular block. Single-chamber devices have been the gold standard for bradycardia, CMS stated in the decision memo.

The evidence does not point to a mortality benefit for dual- over single-chamber devices, but "there is some indication of better secondary outcomes from use of dual-chamber pacemakers, including reduction in occurrence of AFib and improved quality of life," according to CMS.

Representatives from the Heart Rhythm Society and the American College of Cardiology had requested CMS review evidence that has emerged since 2004, when the last update occurred.

Future of TAVI Carries Big Price tag

The number of patients over 75 with severe aortic stenosis who are candidates for transcatheter aortic valve implantation (TAVI) is "substantial" at 3.4%, according to a pooled analysis.

A Monte Carlo model using the current indications for TAVI estimated nearly 300,000 elderly patients at high or prohibitive surgical risk who could be treated with TAVI in Europe and North America, according to the study published online in the Journal of the American College of Cardiology.

There are clinical, economic, and social implications for the estimated large number of TAVI candidates, wrote A. Peter Kappetein, MD, PhD, of Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues.

Using the index admission cost in the PARTNER trial ($72,000), researchers estimated a nearly $14 billion budget impact in Europe and $7.2 billion in North America.

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